Date of Birth

Gender

Medical Record Number

Type: String Description: Patient’s ID number associated with their entire medical record, and not specific to any single hospital visit/admission.

Encounter Number

Type: StringDescription: Patient’s ID number associated with a single hospital visit/admission. An Encounter Number may also be referred to as a Visit Number or Account Number. Importantly, the Encounter Number is barcoded on the patient’s wrist band and is used to identify the patient’s current admission.

Place of Service Code

Type: String Values: IP, AMB (IP = Inpatient, AMB = Ambulatory) Description: This specifies the type of entity where service(s) were rendered. Commonly coded as a value of “21”, “22” or “24”. QCDRs require this information to be submitted with their quality data.

ASA Status with Emergency

Primary Anesthetic

Type: String Values: GENERAL, MAC, SPINAL, REGIONAL, EPIDURAL, LABOR_EPIDURAL, TOPICAL Description: This is the primary type of anesthetic used for the procedure. Even if multiple techniques were used, only one should be selected for this field. Typically when Regional is used in cobmination with General, a “General” anesthetic will be selected.

Care Team

Surgeon NPI

Type: NumericDescription: The 10-digit number assigned to the surgeon of record.

Anesthesia Provider(s) NPI

Type: Numeric Description: The 10-digit number assigned to the anesthesia provider.

Anesthesia Provider(s) Type

Date of Service

Type: DateDescription: The data on which anesthesia service began and equivalent to the Anesthesia Start Date.

OR Location

Type: StringDescription: Name of the anesthetizing location. For example, “OR 1” or “Cath Lab 1”.

Scheduled Start

Type: TimestampDescription: Date and Time the patient was told the case would start.

Anesthesia Start

Type: TimestampDescription: Date and Time the patient arrives to the operating room.

Anesthesia Ready

Type: TimestampDescription: Date and Time the patient has been induced, vascular access obtained, and any regional or neuraxial procedures have been completed. It’s the time the anesthesia team typically allows the surgical team to begin their positioning and prepping of the patient for start of procedure.

Surgery Start

Type: TimestampDescription: Date and Time incision is made or the procedure begins.

Surgery End

Type: TimestampDescription: Date and Time surgery is complete.

PACU/ICU Arrival

Type: TimestampDescription: Date and Time the patient arrives to the either PACU or ICU. If the patient does not “transfer” physcially to another location following anesthesia, this is the time a handoff to another team occurs, in which the new team is responsible for monitoring the patient followin anesthesia.

Anesthesia End

Type: TimestampDescription: Date and Time the continuous anesthetic care as ended.

Process

Transfer location

Type: String Values: PACU, ICU Description: The patient’s area of treatment following their anesthetic. This is used to code certain CMS measures which distinguish if patients are transferred to the PACU or ICU. We also visualize this information in our Population Health charts to help you better understand the acuity of your patients and the effects that may have on average efficiency times.

PACU Pain Score

Type: String Values: 0-10, Unknown Description: The patient’s pain score in the PACU within 15 minutes of arrival. If patient is sedated or otherwise unable to report a score, a value of “unknown” may be reported.

Hypothermia (Temp <35.5 C)

Type: NumericDescription: A temperature of <35.5 degrees centigrade in the immediate postoperative period within 15 minutes of arrival in PACU.

Handoff Protocol Used

Type: BooleanDescription: Percentage of patients, regardless of age, who undergo a procedure under anesthesia who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible care team or team member.

The key handoff elements that must be included in the transfer of care protocol or checklist include:

Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure

Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration.

Opportunity for questions and acknowledgement of understanding of report from the receiving team.

Surgical Safety Checklist Used

Type: BooleanDescription: Percentage of patients, regardless of age, who undergo a surgical procedure under anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of anesthesia.

The WHO Surgical Safety Checklist includes the following items before Induction of Anesthesia:

Has the patient confirmed his/her identity, site, procedure and consent?

Is the site marked?

Is the anesthesia machine and medication check complete?

Is the pulse oximeter on the Patient And Functioning?

Does the Patient have a:

Known Allergy?

Difficult Airway/Aspiration Risk?

Risk of >500 ml Blood Loss (7ml/kg in children)?

Outcomes

Dysrhythmia requiring intervention

Description: Arrhythmia that requires intervention with anti-arrhythmics other than anesthetics. Does not include beta blockade for cases for HR < 100.

Cardiac arrest (unplanned)

Description: Any alteration in cardiac activity requiring CPR and/or unplanned defibrillation within the first 24 hours after the completion of an anesthetic.

Unexpected death

Description: Unexpected death within 24 hours after completion of anesthesia, in-hospital death.

Wrong surgical procedure

Dental trauma

Visual loss

Description: Any loss of visual field or acuity following anesthesia not related periocular treatments (eye drops, ointments, or eye surgery) lasting more than 24 hours.

Malignant Hyperthermia

Description: Suspected MH following induction of general anesthesia requiring treatment with Dantrolene.

Awareness under GA

Description: Awareness under anesthesia occurs when a patient remembers events during surgery/procedure while under general anesthetic. Does not include recall of events during periods of intended intra-operative “wake-up” or sedation.

Other

Description: Mechanism for providers to add any comments/complications they may feel is necessary to report, but not available in any of the options available.

Equipment malfunction

Description: Any malfunction requiring intervention not part of routine device/machine checkout.